Nokea
The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
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The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.
The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?
- A. I have a burning sensation when I urinate.
- B. I have been having some dribbling after I finish urinating.
- C. I missed 3 days of finasteride while on a trip last week.
- D. I was awakened 3 times last night by the need to urinate.
Correct Answer: A
Rationale: Burning on urination (A) suggests a urinary tract infection, requiring investigation. Dribbling (B), nocturia (D), and missing doses (C) are common with BPH or medication non-adherence but less urgent.
The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.
Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?
- A. Check for residual
- B. Measure the pH of aspirated gastrointestinal fluid
- C. Inject 10 to 20 mL of air while auscultating over the epigastric area
- D. Ask the client to talk or hum
Correct Answer: B
Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.
The nurse is screening pediatric clients for developmental dysplasia of the hip (DDH). Which of the following findings would be consistent with DDH in a 3-week-old client?
- A. the leg on the affected side appears longer
- B. narrowing of the perineum
- C. presence of extra gluteal folds on the affected side
- D. pelvic tilt with lordosis
Correct Answer: C
Rationale: Extra gluteal folds (C) are a sign of DDH. The affected leg appears shorter, not longer (A). Narrowing of the perineum (B) and pelvic tilt (D) are not typical.